Basic Information
| Provider Information | |||||||||
| NPI: | 1154779601 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOFFO | ||||||||
| FirstName: | JENNA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PT, DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | COST | ||||||||
| OtherFirstName: | JENNA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PT, DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3430 BURNET AVE # 4007 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452292833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1380355375 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2161 BOLSER DR | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452153933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137556600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2016 | ||||||||
| LastUpdateDate: | 11/05/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251P0200X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 2187155 | 05 | OH | MEDICAID |